A nurse is caring for a client who gave birth 2 hr ago.
The nurse notes that the client's blood pressure is 60/50 mm Hg. Which of the following actions should the nurse take first?.

Evaluate the firmness of the uterus (fundus).

Obtain a type and crossmatch.

Administer oxytocin infusion.

Initiate oxygen therapy by nonrebreather mask.

Answer and Explanation

The Correct Answer is A

The correct answer is choice A.

Choice A rationale:

Evaluating the firmness of the uterus (fundus) is the first action the nurse should take when a client’s blood pressure drops postpartum. A soft or “boggy” uterus can indicate uterine atony, a leading cause of postpartum hemorrhage, which can lead to hypotension.

Choice B rationale:

Obtaining a type and crossmatch is important if the client needs a blood transfusion, but it is not the first action the nurse should take.

Choice C rationale:

Administering oxytocin infusion can help contract the uterus and control bleeding, but the nurse should first assess the uterus.

Choice D rationale:

Initiating oxygen therapy can help if the client is hypoxic, but the nurse should first assess the uterus.

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Correct Answer is ["A","E","F"]

Explanation

The correct answers are choices B, E, and F.

Choice A rationale:

Nausea with vomiting during the first trimester is a common symptom of pregnancy and does not need to be reported immediately to the health care provider.

Choice B rationale:

Sudden leakage of fluid during the second trimester could indicate premature rupture of membranes, which can lead to infection and preterm labor. This should be reported immediately.

Choice C rationale:

Urinary frequency in the third trimester is a common symptom of pregnancy due to the growing uterus putting pressure on the bladder.

Choice D rationale:

Backache during the second trimester is a common symptom of pregnancy as the body adjusts to the growing uterus.

Choice E rationale:

Lower abdominal pain with shoulder pain in the first trimester could indicate an ectopic pregnancy, which is a medical emergency and should be reported immediately.

Choice F rationale:

Headache with visual changes in the third trimester could indicate preeclampsia, a serious condition that can lead to seizures, stroke, and other complications. This should be reported immediately.

A. The infant probably has either a congenital heart defect or an immature respiratory system. B. The infant requires immediate and aggressive interventions for survival. C. The infant is experiencing moderate difficulty in adjusting to extrauterine life. D. The infant is adjusting well to extrauterine life.

Correct Answer is C

Explanation

The correct answer is choice C.

Choice A rationale:

A 1-minute Apgar score of 5 points does not necessarily indicate a congenital heart defect or an immature respiratory system.

Choice B rationale:

An Apgar score of 5 points at 1 minute does not require immediate and aggressive interventions for survival.

Choice C rationale:

A 1-minute Apgar score of 5 points indicates that the infant is experiencing moderate difficulty in adjusting to extrauterine life.

Choice D rationale:

An Apgar score of 5 points at 1 minute does not indicate that the infant is adjusting well to extrauterine life.

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A nurse is caring for a client who gave birth 2 hr ago.The nurse notes that the client's blood pressure is 60/50 mm Hg. Which of the following actions should the nurse take first?.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is ["A","E","F"]

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A nurse is caring for a client who gave birth 2 hr ago.
The nurse notes that the client's blood pressure is 60/50 mm Hg. Which of the following actions should the nurse take first?.